Using machine learning models to predict falls in hospitalised adults

BACKGROUND

Identifying patients at high risk of falling is crucial in implementing effective fall prevention programs. While the integration of information systems is becoming more widespread in the healthcare industry, it poses a significant challenge in analysing vast amounts of data to identify factors that could enhance patient safety.

OBJECTIVE

To determine fall-associated factors and develop high-performance prediction tools for at-risk patients in acute and sub-acute care services in Australia.

METHODS

A retrospective study of 672,400 patients admitted to acute and sub-acute care services within a large metropolitan tertiary health service in Victoria, Australia, between January 1, 2019, and December 31, 2021. Data were obtained from four sources: the Department of Health Victorian Admitted Episodes Dataset, RiskManTM, electronic health records, and the health workforce dataset. Machine learning techniques, including Random Forest and Deep Neural Network models, were used to analyse the data, predict patient falls, and identify the most important risk factors for falls in this population. Model performance was evaluated using accuracy, F1-score, precision, recall, specificity, Matthew's correlation coefficient, and the area under the receiver operating characteristic curve (AUC).

RESULTS

The deep neural network and random forest models were highly accurate in predicting hospital patient falls. The deep neural network model achieved an accuracy of 0.988 and a specificity of 0.999, while the RF achieved an accuracy of 0.989 and a specificity of 1.000. The top 20 variables impacting falls were compared across both models, and 12 common factors were identified. These factors can be broadly classified into three categories: patient-related factors, staffing-related factors, and admission-related factors. Although not all factors are modifiable, they must be considered when planning fall prevention interventions.

CONCLUSION

The study demonstrated machine learning's potential to predict falls and identify key risk factors. Further validation across diverse populations and settings is essential for broader applicability.

Use of Wearable Devices to Monitor Postoperative Activity following Cardiac Surgery. A Systematic Scoping Review

AIM

There is an emerging trend of using wearable digital technology to monitor patient activity levels in acute care contexts. However, the overall extent and quality of evidence for their use in acute cardiac surgery care is unclear. The purpose of this systematic scoping review was to evaluate current literature regarding the use of wearable activity trackers/accelerometers to monitor patient activity levels in the first 30-days following cardiac surgery.

METHOD

A systematic scoping review was conducted. A search of CINAHL and MEDLINE Complete databases identified all peer reviewed research evidence published in English between 2010 and 2023. Studies evaluating the use of wearable, technology in adults who had undergone coronary bypass graft surgery (CAGS), and/valve replacement (VR) were included. Study data was summarised thematically.

RESULTS

A total of 853 citations were identified. Once duplicates were removed, 816 studies were screened by title and abstract, 54 full-text studies were assessed for eligibility and 11 studies included. Accelerometers were able to capture changing exercise and physical activity levels over an acute care admission. Device use was acceptable to clinicians and patients. Low activity levels in the early postoperative period were associated with longer length of stay and higher 30-day readmissions.

CONCLUSION

Wearable devices are acceptable and feasible to use in acute care. Use of wearable activity trackers by acute cardiac patients may increase patient participation in exercise and identify more sedentary patients who are a greater risk of increased length of stay and hospital readmission.

Understanding the provision of goal-concordant care in the intensive care unit: A sequential two-phase qualitative descriptive study

BACKGROUND

Goal-concordant care in intensive care is care that aligns with the patient's expressed goals, values, preferences and beliefs. Communication and shared decision-making are key to ensuring goal-concordant care.

AIMS

The aims of his study were to explore (i) critical care clinicians' perspectives on how patient goals of care were communicated between clinicians, patients, and family in the intensive care unit; (ii) critical care nurses' role in this process; and (iii) how goals of care were used to guide care.

METHOD

Sequential two-phase qualitative descriptive design. Data were collected from February to June 2022 in a level-3 intensive care unit in a private hospital in Melbourne, Australia. In Phase One, individual interviews were conducted with critical care nurse participants (n = 11). In Phase Two, the findings were presented to senior clinical leaders (n = 2) to build a more comprehensive understanding. Data were analysed using Braun and Clarke's six step reflexive thematic analysis.

FINDINGS

There was poor consensus on the term 'goals of care', with some participants referring to daily treatment goals or treatment limitations and others to patients' wishes and expectations beyond the ICU. Critical care nurses perceived themselves as information brokers and patient advocates responsible for ensuring patient goals of care were respected, but engaging in goals-of-care conversations was challenging. A lack of role clarity, poor team communication, and inadequate processes to communicate patient goals impeded goal-concordant care. Senior clinical leaders affirmed these views, emphasising the need to utilise critical care nurses' insight for practical solutions to improve patient care.

CONCLUSIONS

Clarity in both, the term 'goals of care' and the critical care nurses' role in these conversations, are the essential first steps to ensuring patients' values, preferences, and beliefs to guide shared-decision-making and goal-concordant care. Improved verbal and written communication that is inclusive of all members of the treating team is key to addressing these issues.

Evaluation of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) a staff simulation training intervention to improve palliative care of people with advanced dementia living in nursing homes: a cluster randomised controlled trial

Background

People with dementia have unique palliative and end-of-life needs. However, access to quality palliative and end-of-life care for people with dementia living in nursing homes is often suboptimal. There is a recognised need for nursing home staff training in dementia-specific palliative care to equip them with knowledge and skills to deliver high quality care.

Objective

The primary aim was to evaluate the effectiveness of a simulation training intervention (IMPETUS-D) aimed at nursing home staff on reducing unplanned transfers to hospital and/or deaths in hospital among residents living with dementia.

Design

Cluster randomised controlled trial of nursing homes with process evaluation conducted alongside.

Subjects & setting

One thousand three hundred four people with dementia living in 24 nursing homes (12 intervention/12 control) in three Australian cities, their families and direct care staff.

Methods

Randomisation was conducted at the level of the nursing home (cluster). The allocation sequence was generated by an independent statistician using a computer-generated allocation sequence.

Staff from intervention nursing homes had access to the IMPETUS-D training intervention, and staff from control nursing homes had access to usual training opportunities. The predicted primary outcome measure was a 20% reduction in the proportion of people with dementia who had an unplanned transfer to hospital and/or death in hospital at 6-months follow-up in the intervention nursing homes compared to the control nursing homes.

Results

At 6-months follow-up, 128 (21.1%) people with dementia from the intervention group had an unplanned transfer or death in hospital compared to 132 (19.0%) residents from the control group; odds ratio 1.14 (95% CI, 0.82-1.59). There were suboptimal levels of staff participation in the training intervention and several barriers to participation identified.

Conclusion

This study of a dementia-specific palliative care staff training intervention found no difference in the proportion of residents with dementia who had an unplanned hospital transfer. Implementation of the intervention was challenging and likely did not achieve adequate staff coverage to improve staff practice or resident outcomes.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618002012257. Registered 14 December 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02809-x.

Impact of Pain on Postoperative Recovery and Participation in Care Following Knee Arthroplasty Surgery: A Qualitative Descriptive Study

BACKGROUND

Patient participation in care is key to optimising postsurgical outcomes and the quality of acute care delivery.

AIMS

This study explored patient perceptions of the impact of pain on acute recovery following Total Knee Arthroplasty (TKA), and barriers and facilitators to participating in pain management.

DESIGN

An exploratory-descriptive qualitative study involving semi-structured interviews.

SETTINGS

A private-sector health service.

PARTICIPANTS/SUBJECTS

Participants were adults undergoing TKA allocated to the control ward of a cluster randomised controlled trial who received standard care.

METHODS

To allow adequate opportunity for participation in their care, interview and pain data were collected on postoperative Day 3. Acute pain was assessed using an 11-point Numerical Rating Scale (NRS). Interviews were analysed using combined qualitative thematic analysis and quantitative content analysis.

RESULTS

Overall, 120 patients, 69 females (50.4%) and 68 males, were interviewed (mean age = 66.8 years, stadard deviation [SD] = 8.5). Most reported severe (NRS 7-10), day 3 pain (n = 76, 63.3%). Two themes emerged from interviews: (1) participants' postoperative pain experience; and (2) participation in postoperative pain management was limited. Pain experience was characterised by variation in pain and its qualities, having uncontrolled pain and distress, and influence from preoperative expectations. Patient participation was characterized by reliance upon prior staff instruction, barriers from limited knowledge, inconsistent promotion of non-pharmacologic strategies, and suboptimal clinician-patient communication. Regular analgesia was identified to facilitate participation.

CONCLUSIONS

Despite the known benefits of patient participation in pain management, gaps remain in providing patients with the knowledge and opportunity to take an active role in their recovery. Interventions to overcome identified barriers need to be developed and evaluated.

Inter-rater reliability and predictive accuracy of the Shkuratova Assessment of Falls-risk in Rehabilitation (SAFER) tool

Despite the recognised importance of falls prevention in rehabilitation settings, there is limited research focusing on falls risk assessment tools designed to guide both patient screening and therapy. This study evaluated the predictive accuracy and inter-rater reliability of the Shkuratova Assessment of Falls-risk in Rehabilitation settings (SAFER) tool. The study was conducted at a subacute rehabilitation facility in Australia. Patient assessments were performed on admission to subacute care by trained physiotherapists, and the incidence of falls was documented prospectively. Of the 147 patients, 45 had at least one fall and were compared to 102 who had no falls. The inter-rater reliability of the SAFER tool when used by trained physiotherapists was high with the level of agreement for individual items ranging from 74 to 99%. Thirty-two (76%) patients who experienced a fall during their admission and 46 (44%) who did not fall were identified as having a high falls-risk. Using a SAFER tool cut-off of 12/26: sensitivity is 69%, specificity is 66%, area under the curve 0.71 (95% confidence interval: 0.62-0.80). The high negative predictive values at a range of cut-offs provided strong evidence that patients identified as having a low falls-risk were unlikely to experience a fall. Performing a comprehensive assessment of specific deficits in gait, balance and mobility on admission provided a streamlined approach to identification of patients who would benefit from tailored falls prevention interventions.

Nursing students' awareness and perceptions of nurses' role in antimicrobial stewardship

Antimicrobial resistance is a major threat to public health worldwide. Antimicrobial stewardship programs and interventions aiming to optimise the use of antibiotics, are increasingly used to ensure judicious use of antibiotics and limit the emergence of antimicrobial resistance. Nurses are pivotal in antimicrobial stewardship however nursing students' awareness of such programs has not been investigated. This study aimed to elicit nursing students' perspectives and perceptions of the nurse's role in antimicrobial stewardship. A cross-sectional design was utilised to survey pre-registration nursing students. A total of 321 nursing students enrolled in an Australian university participated. The survey comprised questions on knowledge and opinions regarding the nurse's role in AMS and on a range of topics relating to antimicrobial stewardship and antimicrobial resistance, through closed and open-ended questions. While 44.5% of participants indicated they were familiar with the term Antimicrobial Stewardship, 70.7% believed they had very little or no knowledge of the principles. Completion of subjects with a focus on quality and safety in nursing practice and quality use of medications was associated with greater awareness. Findings underscore the need to engage nursing students in discussions exploring the problem of antimicrobial resistance and the important role nurses play in Antimicrobial Stewardship programs.

The relationship between the undergraduate clinical learning environment and work readiness in new graduate nurses: A pre-post survey study

BACKGROUND

Due to projected nurse shortages, it is necessary that undergraduate programs optimise work readiness outcomes in new graduate nurses. Research that quantitatively evaluates characteristics of clinical nursing programs that predict increased work readiness is required.

OBJECTIVES

To explore the relationship between the undergraduate clinical learning environment and nurse perceptions of work readiness prior to and following, commencement as a new graduate nurse.

DESIGN

A pre-post follow-up study. Undergraduates were surveyed at the end of their Bachelor's degree (baseline) and at 8-10 weeks after commencement as a graduate nurse (Time 1).

SETTING

A multi-site, metropolitan private hospital in Victoria, Australia.

PARTICIPANTS

Nursing graduates who completed a university fellowship program (n = 26), or were undertaking their graduate year and had completed placement blocks within (n = 18) or outside (n = 31) the healthcare organisation.

METHODS

Participants self-completed the Clinical Learning Environment Inventory (CLEI) and Work Readiness Scale for Graduate Nurses (WRS-GN) at baseline and Time 1. Multiple regression analyses were performed.

RESULTS

CLEI scores significantly predicted work readiness outcomes (all p-values<.05), accounting for 16-36% and 17-28% of the variance of WRS-GN scores at baseline and Time 1, respectively. After adjusting for clustering due to clinical placement groups, CLEI Individualisation (p = .023) and Valuing Nurses Work (p = .01) predicted improved Time 1 WRS-GN Organisational Acumen. CLEI Innovative and Adaptive Culture scores predicted poorer Time 1 Organisational Acumen (p = .001).

CONCLUSIONS

Learning environments that offered high levels of individualised attention and valued nurses' work appeared to facilitate post-graduation engagement and identification with nursing practice. However, highly innovative and adaptive education may detract from optimal work readiness. Findings revealed that while important, the clinical learning environment only accounted for a small-to-moderate degree of nursing graduates' work readiness. To facilitate robust evidence-based improvement of clinical nursing education, future research should attempt to empirically establish the value of additional facilitators of work readiness.

Effectiveness of strategies to increase uptake of pertussis vaccination by new parents and family caregivers: A systematic review

OBJECTIVES

Cocoon immunisation strategies involve administration of Bordetella pertussis containing vaccines to parents and family members who are in close contact with newborns. The objective of this systematic review was to evaluate the effectiveness of strategies to increase uptake of vaccination against Bordetella pertussis infection by parents and family caregivers of newborn children (< 3 months of age).

DESIGN

A protocol driven systematic review was conducted between 2005 and February 2020. CINAHL, Medline, and Google Scholar databases were searched.

SETTING

Inpatient maternity care units, ante-natal and post-natal clinics based in acute care or primary/community care contexts.

PARTICIPANTS

(i) mothers, (ii) fathers and (iii) family caregivers or other regular household contacts of infants < 3 months of age.

INTERVENTIONS

Health promotion interventions and immunisation clinics designed to promote "cocoon immunisation" against Bordetella pertussis infections of the newborn.

MEASUREMENTS

Change in uptake of adult vaccination with a pertussis containing vaccine (dTpa or Tdap) by new parents and family caregivers.

FINDINGS

Eight studies were included in this review. Strategies used to promote vaccination included: written and verbal education, promotional videos, provision of vaccine prescriptions and financial incentives, opportunistic vaccination of family members and population-based health promotional messaging. Six of the eight studies reported positive impacts on vaccination uptake. Four studies evaluating providing opportunistic immunisation during the obstetric admission reported statistically significant increases in maternal (+39% to +57%), paternal (+21% to +52%) and household members (+32%) vaccination rates. Targeted public health campaigns were also found to increase vaccination uptake but in isolation were insufficient to achieve vaccination of all household contacts.

CONCLUSION

Promotion of pertussis vaccination to new parents and the provision of opportunistic vaccination during the obstetric admission or post-natal visit, was the most successful strategy to increase uptake of pertussis vaccination by family caregivers.

Resuscitation status and characteristics and outcomes of patients transferred from subacute care to acute care hospitals: A multi-site prospective cohort study

AIMS AND OBJECTIVES

To examine the relationship between resuscitation status and (i) patient characteristics; (ii) transfer characteristics; and (iii) patient outcomes following an emergency inter-hospital transfer from a subacute to an acute care hospital.

BACKGROUND

Patients who experience emergency inter-hospital transfers from subacute to acute care hospitals have high rates of acute care readmission (81%) and in-hospital mortality (15%).

DESIGN

This prospective, exploratory cohort study was a subanalysis of data from a larger case-time-control study in five Health Services in Victoria, Australia. There were 603 transfers in 557 patients between August 2015 and October 2016. The study was conducted in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines.

METHODS

Data were extracted by medical record audit. Three resuscitation categories (full resuscitation; limitation of medical treatment (LOMT) orders; or not-for-cardiopulmonary resuscitation (CPR) orders) were compared using chi-square or Kruskal-Wallis tests. Stratified multivariable proportional hazard Cox regression models were used to account for health service clustering effect.

FINDINGS

Resuscitation status was 63.5% full resuscitation; 23.1% LOMT order; and 13.4% not-for-CPR. Compared to patients for full resuscitation, patients with not-for-CPR or LOMT orders were more likely to have rapid response team calls during acute care readmission or to die during hospitalisation. Patients who were not-for-CPR were less likely to be readmitted to acute care and more likely to return to subacute care.

CONCLUSIONS

Two-thirds of patients in subacute care who experienced an emergency inter-hospital transfer were for full resuscitation. Although the proportion of patients with LOMT and not-for-CPR orders increased after transfer, there were deficiencies in the documentation of resuscitation status and planning for clinical deterioration for subacute care patients.

RELEVANCE TO CLINICAL PRACTICE

As many subacute care patients experience clinical deterioration, patient preferences for care need to be discussed and documented early in the subacute care admission.

Usability and feasibility of multimedia interventions for engaging patients in their care in the context of acute recovery: A narrative review

PURPOSE

The purpose of this narrative review was to examine the usability and feasibility of multimedia intervention as a platform to enable patient participation in the context of acute recovery and to discover what outcomes have been measured.

DATA SOURCES

A narrative review of primary research articles identified through a search of four electronic databases (MEDLINE, CINAHL, EMBASE and PsycInfo) identified peer-reviewed research evidence published in English language with no limitation placed on time period or publication type. Two authors independently assessed articles for inclusion. From the 277 articles identified through the search, 10 papers reporting the outcomes of seven studies were included in this review.

REVIEW METHODS

Articles were independently assessed for quality and relevance by two authors. The most appropriate method for data synthesis for this review was a narrative synthesis.

RESULTS

From the narrative synthesis of study outcomes, two findings emerged as follows: (a) multimedia interventions are feasible and usable in the context of acute care, and (b) multimedia interventions can improve patients' perception of care-related knowledge. Identified gaps included a lack of evidence in relation to the effect of interventions on enhancing patients' ability to participate in their care and the impact on patients' health-related outcomes.

CONCLUSIONS

In conclusion, there is some evidence of the feasibility and usability of multimedia interventions in acute care. That is, patients can use these types of platforms in this context and are satisfied with doing so. Multimedia platforms have a role in the delivery of information for patients during acute recovery; however, the effectiveness of these platforms to engage and enhance patients' capability to participate in their recovery and the impact on outcomes needs to be rigorously evaluated.

A screen-based simulation training program to improve palliative care of people with advanced dementia living in residential aged care facilities and reduce hospital transfers: study protocol for the IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) cluster randomised controlled trial

Background

Many people with advanced dementia live in residential aged care homes. Care home staff need the knowledge and skills to provide high-quality end-of-life (EOL) dementia care. However, several studies have found EOL dementia care to be suboptimal, and care staff have reported they would benefit from training in palliative care and dementia. Simulation offers an immersive learning environment and has been shown to improve learners’ knowledge and skills. However, there is little research on simulation training for residential care staff.

This article presents the development and evaluation protocol of IMproving Palliative care Education and Training Using Simulation in Dementia (IMPETUS-D) - a screen-based simulation training program on palliative dementia care, targeted at residential care staff. IMPETUS-D aims to improve the quality of palliative care provided to people living with dementia in residential care homes, including avoiding unnecessary transfers to hospital.

Methods

A cluster RCT will assess the effect of IMPETUS-D. Twenty-four care homes (clusters) in three Australian cities will be randomised to receive either the IMPETUS-D intervention or usual training opportunities (control). The primary outcome is to reduce transfers to hospital and deaths in hospital by 20% over 6-months in the intervention compared to the control group. Secondary outcomes include uptake of goals of care plans over 6 and 12 months, change in staff knowledge and attitudes towards palliative dementia care over 6 months, change in transfers to hospital and deaths in hospital over 12 months. For the primary analysis logistic regression models will be used with standard errors weighted by the cluster effects. A mixed methods process evaluation will be conducted alongside the cluster RCT to assess the mechanisms of impact, the implementation processes and contextual factors that may influence the delivery and effects of the intervention.

Discussion

In Australia, the need for high-quality advanced dementia care delivered in residential aged care is growing. This study will assess the effect of IMPETUS-D a new simulation-based training program on dementia palliative and EOL care. This large multisite trial will provide robust evidence about the impact of the intervention. If successful, it will be distributed to the broader residential care sector.

Trial registration

ANZCTR, ACTRN12618002012257. Registered 14 December 2018.

Use of excessive supplemental oxygen in mechanically ventilated patients is based on unit culture. A multiple-methods study in a regional intensive care unit

BACKGROUND

Administration of supplemental oxygen is widely used in the management of critically ill patients; however, there is evidence that excessive supplemental oxygen exposure is associated with increased mortality. There is limited research evaluating what factors clinicians take into consideration when managing oxygenation in critically ill adults.

OBJECTIVES

The purpose of this study was to explore intensive care unit (ICU) clinicians' experience and decision-making when managing supplemental oxygen therapy in mechanically ventilated patients in a regional intensive care unit.

METHODS

A multiple-methods observational study that included (i) a cross-sectional ICU staff survey and (ii) focus group discussions with critical care nurses was conducted. Descriptive statistics were used to summarise the key outcomes of the staff survey. Thematic analysis was used to analyse the focus group discussions and open-ended questions on the staff survey. The staff survey was completed by 49 ICU clinicians, and 11 critical care nurses participated in the two focus group discussions.

RESULTS

Survey data showed that staff acknowledged the problem of excessive oxygen exposure; 79.6% (n = 39) reported that the minimum acceptable fraction of inspired oxygen for mechanically ventilated patients was 0.3. The majority (89.8%, n = 44) reported that there was an interdisciplinary approach to decision-making in the unit. Two major themes were chosen from the focus group discussions and staff survey data: (i) Decision-making is based on unit culture rather than evidence and (ii) the process of weaning is driven by interdisciplinary team collaboration. Participants acknowledged that there needed to be a culture change from a liberal approach to oxygen therapy.

CONCLUSIONS

Although participants acknowledged the adverse consequences of excessive oxygen use, achieving oxygenation targets with the minimum level of supplemental oxygen was not a key focus of care. The findings highlight the need to develop and evaluate evidence-based protocols to support a conservative approach to supplemental oxygen management.

Patient activation intervention to facilitate participation in recovery after total knee replacement (MIME): a cluster randomised cross-over trial

Background

Patient participation in care is a fundamental element of safe and high-quality healthcare with the potential to enhance health outcomes and improve patient satisfaction.

Objectives

To test the efficacy of a clinician-facilitated, bedside multimedia (MyStay) intervention designed to support patient participation in their recovery after total knee replacement surgery. The primary outcome was patients’ reported worst pain intensity on postoperative day 3. Secondary outcomes were patient activation, length of hospital stay, knee function and satisfaction with care.

Methods

Unmasked, cluster randomised, four-period cross-over trial with a simultaneous process evaluation within in a large private, not-for-profit, metropolitan teaching hospital. Statistical analyses used linear mixed models with random effects for wards, cohorts within wards and patients within cohorts and fixed effects for treatment and period.

Results

241 patients were recruited between March 2014 and June 2015. Patients were admitted to intervention (104) or control (137) clusters. Intervention group patients reported significantly lower mean pain intensity scores on postoperative day 3 (6.1 vs 7.1, 95% CI −1.94 to −0.08, p=0.04). The percentages of patients who reported severe pain (score ≥7) were 43.7% and 64.2% in the intervention and control groups, respectively (χ² 9.89, p=0.002; generalised linear mixed model Wald test, p=0.05). Intervention group patients on average stayed in hospital one less day (5.3 vs 6.3, 95% CI 0.05 to 1.94, p=0.04), reported higher activation (45.1% vs 27.1% at level 4 activation) (p=0.04) and higher overall satisfaction with care (9.3 vs 8.6, 95% CI 1.09 to 0.219, p=0.01), and were more likely to refer family or friends to the health service (9.3 vs 8.7, 95% CI 1.07 to 0.13, p=0.02).

Conclusion

The clinician-facilitated, MyStay bedside multimedia intervention enhanced patients’ activation and participation in their care after surgery; pain intensity and length of stay in hospital were reduced and patients were more satisfied with their care.

Trial registration

ACTRN12614000340639 (http://www.anzctr.org.au/default.aspx).

Relationship between health-related quality of life, comorbidities and acute health care utilisation, in adults with chronic conditions

Background

There is increased interest in developing multidisciplinary ambulatory care models of service delivery to manage patients with complex chronic diseases. These programs are expensive and given limited resources it is important that care is targeted effectively. One potential screening strategy is to identify individuals who report the greatest decrement in health related quality of life (HRQoL) and thus greater need. The aim of this study was to explore the relationship between HRQoL, comorbid conditions and acute health care utilisation.

Methods

A prospective, longitudinal cohort design was used to evaluate the impact of HRQoL on acute care utilisation rates over three-years of follow-up. Participants were enrolled in chronic disease management programs run by a metropolitan health service in Australia. Baseline data was collected from 2007–2009 and follow-up data until 2012. Administrative data was used to classify patients’ primary reasons for enrolment, number of comorbidities (Charlson Score) and presentations to acute care. At enrolment, HRQoL was measured using the Assessment of Quality of Life (AQoL) instrument, for analysis AQoL scores were dichotomised at two standard deviations below the population norm.

Results

There were 1999 participants (54 % male) with a mean age of 63 years (range 18–101), enrolled in the study. Participants’ primary health conditions at enrolment were: diabetes 915 (46 %), chronic respiratory disease 463 (23 %), cardiac disease 260 (13 %), peripheral vascular disease, and 181 (9 %) and aged care 180 (9 %). At 1-year multivariate logistic regression models demonstrated that AQOL utility score was not predictive of acute care presentations after adjusting for comorbidities. Over 3-years an AQoL utility score in the lowest quartile was predictive of both ED presentation (OR 1.58, 95 % CI, 1.16–2.13, p = 0.003) and admissions (OR 1.67, 95 % CI.1.21 to 2.30, p = 0.002) after adjusting for differences in age and comorbidities.

Conclusion

This study found that both HRQoL and comorbidities were predictive of subsequent acute care attendance over 3-years of follow-up. At 1-year, comorbidities was a better predictor of acute care representation than HRQoL. To maximise benefits, programs should initially focus on medical disease management, but subsequently switch to strategies that enhance health independence and raise HRQoL.

A longitudinal cohort study evaluating the impact of a geriatrician-led residential care outreach service on acute healthcare utilisation

BACKGROUND

over the last decade, high demand for acute healthcare services by long-term residents of residential care facilities (RCFs) has stimulated interest in exploring alternative models of care. The Residential Care Intervention Program in the Elderly (RECIPE) service provides expert outreach services to RCFs residents, interventions include comprehensive care planning, management of inter-current illness and rapid access to acute care substitution services.

OBJECTIVE

to evaluate whether the RECIPE service decreased acute healthcare utilisation.

DESIGN

a retrospective cohort study using interrupted time series analysis to analyse change in acute healthcare utilisation before and after enrolment.

SETTING

a 300-bed metropolitan teaching hospital in Australia and 73 RCFs within its catchment.

SUBJECTS

there were 1,327 patients enrolled in the service with a median age of 84 years; 61% were female.

METHODS

data were collected prospectively on all enrolled patients from 2004 to 2011 and linked to the acute health service administrative data set. Primary outcomes change in admission rates, length of stay and bed days per quarter.

RESULTS

in the 2 years prior to enrolment, the mean number of acute care admissions per patient per year was 3.03 (SD 2.9) versus post 2.4 (SD 3.3), the service reducing admissions by 0.13 admissions per patient per quarter (P = 0.046). Prior to enrolment, the mean length of stay was 8.6 (SD 11.0) versus post 3.5 (SD 5.0), a reduction of 1.5 days per patient per quarter (P = 0.003).

CONCLUSIONS

this study suggests that an outreach service comprising a geriatrician-led multidisciplinary team can reduce acute hospital utilisation rates.

Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial

OBJECTIVES

To determine whether outcomes for patients with cellulitis treated with oral antimicrobials are as good as for those who are treated with parenteral antimicrobials.

METHODS

A prospective randomized non-inferiority trial was conducted at a tertiary teaching hospital in Melbourne, Australia. Participants were patients referred by the emergency department for treatment of uncomplicated cellulitis with parenteral antimicrobials. Patients were randomized to receive either oral cefalexin or parenteral cefazolin. Parenteral antimicrobials were changed to oral after the area of cellulitis ceased progressing. The primary outcome was days until no advancement of the area of cellulitis. A non-inferiority margin of 15% was set for the oral arm compared with the parenteral arm. Secondary outcomes were failure of treatment, pain, complications and satisfaction with care. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12611000685910).

RESULTS

Twenty-four patients were randomized to oral antimicrobials and 23 to parenteral antimicrobials. Mean days to no advancement of cellulitis was 1.29 (SD 0.62) for the oral arm and 1.78 (SD 1.13) for the parenteral arm, with a mean difference of -0.49 (95% CI: -1.02 to +0.04). The upper limit of the 95% CI of the difference in means of +0.04 was below the 15% non-inferiority margin of +0.27 days, indicating non-inferiority. More patients failed treatment in the parenteral arm (5 of 23, 22%) compared with the oral arm (1 of 24, 4%), although this difference was not statistically significant (P=0.10). Pain, complications and satisfaction with care were similar for both groups.

CONCLUSIONS

Oral antimicrobials are as effective as parenteral antimicrobials for the treatment of uncomplicated cellulitis.

Effect of a chronic disease management service for patients with diabetes on hospitalisation and acute care costs

Objective. To evaluate the effect of a diabetes-management program for patients with type 2 diabetes and related comorbidities on acute healthcare utilisation and costs. Methods. This was a retrospective administrative dataset analysis using data for patients enrolled from 2007 to 2008. Inpatient admissions for diabetes-related conditions were compared before, during and following enrolment. Costs per episode were estimated from Weighted Inlier Equivalent Separations (WIES) funding. A cost model was then developed based on admission rates per 100 patients. Results. Data were retrieved for 357 patients; 49% males, mean age 62 years. The mean per-patient cost of the program was AU$524 (s.d. $213). The mean cost of an inpatient admission was $4357(95% CI 2743–5971) pre-enrolment and $4396 (95% CI 2888–5904) post-enrolment. Following program completion the annual costs (per 100 patients) for managing ‘diabetes with multiple complications’ and hypoglycaemia decreased from $10 181 to $1710 and $9947 to $7800. In contrast, the annual cost of cardiovascular disorders increased from $14 485 to $40 071 per 100 patients. Conclusions. In the short-term diabetes-management programs for patients with comorbid vascular disease may reduce hospital utilisation for diabetes but not for cardiovascular disease. Longer-term follow-up is needed to determine whether intensive management of vascular complications can reduce costs. What is known about the topic? Type 2 diabetes is now recognised as the fastest growing chronic disease in Australia and other western countries. In developed countries, diabetes is a leading cause of cardiovascular disease and renal failure, and, in the over 60 age group, is a leading cause of blindness and non-traumatic lower limb amputations. Glycated haemoglobin (HbA1c) is a measure of diabetes control, with set target levels for the prevention or delay of development of macrovascular and microvascular complications of diabetes. Epidemiological studies have demonstrated that a 1% reduction in HbA1c can lead to a 15–21% reduction in diabetes-related deaths and 33–41% reduction in microvascular complications over a 10-year period. Indicating that improvements in glycaemic control may have the potential to decrease acute healthcare costs associated with management of complications over the long term. What does this paper add? There are limited data available on the short to medium term effect of disease-management programs for patients with already established complications on acute healthcare utilisation. This study evaluated the cost of providing the Northern Alliance Hospital Admission Risk Program for diabetes disease management and its effect on acute healthcare utilisation at Northern Health. In contrast, the overall inpatient costs for the management of diabetes and related conditions were high and did not decrease significantly following program completion. The major acute care cost drivers were surgical interventions for advanced peripheral vascular disease and the management of cardiovascular events. What are the implications for practitioners? These findings demonstrate that in this population with a high prevalence of established cardiovascular and peripheral vascular complications that diabetes-management programs need to be equipped and resourced to manage these complications if potential savings in acute care costs are to be realised.

Changes in the BODE index, exacerbation duration and hospitalisation in a cohort of COPD patients

INTRODUCTION

We investigated the relationship between frequency of exacerbation and duration and change in functional status, as measured by the BODE index in chronic obstructive pulmonary disease (COPD) patients.

METHODS

This was a longitudinal cohort study of 56 patients with moderate to severe COPD. Body mass index, spirometry, Modified Medical Research Council (MMRC) dyspnoea score and six-minute walk distance (6MWD) were measured annually when the patients were clinically stable. Data on frequency and duration of COPD exacerbations occurring in the community and requiring hospitalisation were collected prospectively. Early stage exacerbations were identified through the use of individualised patient action plans and further reinforced by fortnightly phone contact.

RESULTS

At the two-year follow-up, the BODE index increased in 33 patients, remained stable in 18 and decreased in five patients. Patients with increased BODE index had significantly higher hospital presentation rates and longer total bed-days compared to those with stable BODE index. Among the 33 patients with increased BODE index, 20 had lower 6MWD and higher MMRC scores, indicating deteriorating functional status, and 13 had higher levels of airway obstruction. Between these two subgroups, patients with deteriorating functional status had higher exacerbation frequency, longer exacerbation duration and higher inpatient bed-days. Linear regression showed that total annual duration of exacerbation was predictive of change in 6MWD.

CONCLUSION

Change in the BODE index is a sensitive measure of deteriorating functional status in COPD patients. Duration of exacerbation has greater impact on functional status than frequency of exacerbation episodes.

Communicating information regarding human H1N1-09 virus to high-risk consumers: knowledge and understanding of COPD patients in Melbourne, Australia

BACKGROUND

One of the public health challenges during an influenza pandemic is how to rapidly access groups of high-risk individuals to ensure that they have accurate information regarding prevention and management of infection. The aim of this survey was to evaluate the level of understanding of the H1N1-09 (Swine Flu) pandemic, amongst a high-risk group of individuals with chronic lung disease. This study was conducted in Melbourne, Australia towards the end of the 2009 pandemic.

METHODS

Questions included in the survey were based on the consumer information sheets available from the Department of Health (Victoria) website (frequently asked questions for the general public). Participants were recruited from patients attending community-based programs for chronic lung disease.

RESULTS

Eighty participants were interviewed in August-September 2009, the majority 70/80 were aware of the H1N1-09 pandemic in Melbourne. Most participants gained their information from media reports rather than health care providers. Although they were aware of some ways to decrease the spread of infection, only 20/80 (25%) knew that there were antiviral treatments available if they did contract the infection. It is noteworthy that in a substantial minority (25%), information reported in the media caused some confusion or anxiety and it appears that there was a gap in the provision of evidence-based information to this high-risk group.

CONCLUSION

In the context of future pandemics, respiratory-outreach nurses and educators could be used to promote pertinent information regarding infection prevention and management to high-risk individuals. Currently this appeared to be an under-utilised means of imparting pandemic information to consumers.

Identifying viral infections in vaccinated Chronic Obstructive Pulmonary Disease (COPD) patients using clinical features and inflammatory markers

Background  Known inflammatory markers have limited sensitivity and specificity to differentiate viral respiratory tract infections from other causes of acute exacerbation of COPD (AECOPD). To overcome this, we developed a multi‐factorial prediction model combining viral symptoms with inflammatory markers.

Methods  Interleukin‐6 (IL‐6), serum amyloid A (SAA) and viral symptoms were measured in stable COPD and at AECOPD onset and compared with the viral detection rates on multiplex PCR. The predictive accuracy of each measure was assessed using logistic regression and receiver operating characteristics curve (ROC) analysis.

Results  There was a total of 33 viruses detected at the onset of 148 AECOPD, the majority 26 (79%) were picornavirus. Viral symptoms with the highest predictive values were rhinorrhoea [Odds ratio (OR) 4·52; 95% CI 1·99–10·29; P < 0·001] and sore throat (OR 2·64; 95% CI 1·14–6·08; P = 0·022), combined the AUC ROC curve was 0·67. At AECOPD onset patients experienced a 1·6‐fold increase in IL‐6 (P = 0·008) and 4·5‐fold increase in SAA (P < 0·001). The addition of IL‐6 to the above model significantly improved diagnostic accuracy compared with symptoms alone (AUC ROC 0·80 (P = 0·012).

Conclusion  The addition of inflammatory markers increases the specificity of a clinical case definition for viral infection, particularly picornavirus infection.

A community-based, time-matched, case-control study of respiratory viruses and exacerbations of COPD

Respiratory viruses are associated with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) in hospitalized patients. However, exacerbations are increasingly managed in the community, where the role of viruses is unclear. In community exacerbations, the causal association between viruses and exacerbation maybe confounded by random fluctuations in the prevalence of circulating respiratory viruses. Therefore, to determine whether viral respiratory tract infections are causally associated with community exacerbations, a time-matched case-control study was performed. Ninety-two subjects (mean age 72 yrs), with moderate to severe COPD, (mean FEV(1) 40% predicted), were enrolled. Nasopharyngeal swabs for viral multiplex polymerase chain reaction and atypical pneumonia serology were obtained at exacerbation onset. Control samples were collected in synchrony, from a randomly selected stable patient drawn from the same cohort. In 99 weeks of surveillance, there were 148 exacerbations. Odds of viral isolation were 11 times higher in cases, than their time-matched controls (34 discordant case-control pairs; in 31 pairs only the case had virus and in three pairs only control). Picornavirus (26), influenza A (3), parainfluenza 1,2,3 (2), respiratory syncytial virus (1), and adenovirus (1) were detected in cases while adenovirus (1) and picornavirus (2) were detected in controls. In patients with moderate or severe COPD the presence of a virus in upper airway secretions is strongly associated with the development of COPD exacerbations. These data support the causative role of viruses in triggering COPD exacerbations in the community.